What is the treatment for persistent rhinorrhea (runny nose) and nasal congestion lasting 2 weeks with no improvement?

Treatment for Persistent Rhinorrhea and Nasal Congestion After 2 Weeks

Start intranasal corticosteroids (fluticasone, mometasone, or budesonide) as first-line therapy, and if symptoms persist beyond 3 weeks despite treatment, escalate to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, maximum 2g every 12 hours) for 10-14 days while continuing the nasal steroid. 1, 2

Initial Assessment at 2 Weeks

At the 2-week mark, you need to determine whether this represents:

• Acute bacterial rhinosinusitis (ABRS): Symptoms persisting ≥10 days without improvement, or worsening within 10 days after initial improvement ("double sickening") 3
• Viral rhinosinusitis: Typically resolves within 10 days 3
• Chronic rhinosinusitis (CRS): Symptoms lasting ≥12 weeks 3

Key clinical distinction: ABRS is diagnosed when purulent nasal drainage, nasal obstruction, and localized sinus pain/pressure persist without improvement for at least 10 days 3. However, imaging cannot distinguish bacterial from viral etiology and is not recommended at this stage 3.

First-Line Treatment (Weeks 2-3)

Intranasal Corticosteroids

Begin with intranasal corticosteroids as the most effective single agent for controlling both rhinorrhea and congestion. 2, 4, 5, 6

• Fluticasone propionate: 200 mcg once daily (two 50-mcg sprays per nostril) or 100 mcg twice daily 4
• Demonstrated significant reduction in total nasal symptom scores including rhinorrhea, nasal obstruction, sneezing, and nasal itching 4
• More effective than antihistamines for nasal congestion 2, 5, 6

Add Nasal Saline Irrigation

• Beneficial as adjunctive treatment for chronic rhinorrhea 2
• Improves mucociliary clearance 1

Consider Adding Intranasal Antihistamine

If rhinorrhea persists despite corticosteroids:

• Add azelastine 0.15%: One spray per nostril twice daily 7
• Combination more effective than either drug alone without increased adverse events 2
• Provides symptom relief within 3 hours 7

Critical pitfall to avoid: Do not use topical decongestants beyond 3 days—rhinitis medicamentosa can develop as early as 3 days with regular use 2.

Escalation at 3 Weeks (Treatment Failure)

If symptoms persist or worsen after 3 weeks of appropriate medical therapy, this represents treatment failure requiring antibiotic escalation. 1

Antibiotic Therapy

Switch to high-dose amoxicillin-clavulanate: 1

• Dosing: 90 mg/kg amoxicillin component with 6.4 mg/kg clavulanate, maximum 2g every 12 hours
• Duration: 10-14 days, continuing until symptomatically improved to near normal 1
• Alternative if penicillin-allergic: Cephalosporins 1

Continue Adjunctive Therapy

• Maintain intranasal corticosteroids to reduce mucosal inflammation 1
• Consider short-term oral corticosteroids if marked mucosal edema or nasal polyposis is suspected 1
• Continue nasal saline irrigation 1

When to Image

Order CT scan of sinuses if: 1

• Symptoms fail to improve after appropriate antibiotic therapy
• Complications suspected (headache, facial swelling, orbital proptosis, cranial nerve palsies) 3
• Need to identify anatomical abnormalities or extent of disease 1

Do not obtain imaging for uncomplicated acute rhinosinusitis—it cannot distinguish bacterial from viral etiology 3.

Red Flags Requiring Specialist Referral

Refer to Otolaryngology if: 1

• Structural abnormalities identified on imaging
• Recurrent episodes (≥4 discrete episodes per year) 3
• Symptoms persist beyond 12 weeks (chronic rhinosinusitis) 3

Refer to Allergy/Immunology if: 1

• Underlying allergic rhinitis suspected
• Recurrent infections suggesting immunodeficiency
• Need for evaluation of unusual pathogens

Common Clinical Pitfalls

1. Prescribing antibiotics too early: Most cases at 2 weeks are still viral and will resolve with symptomatic treatment alone 3

2. Using inadequate antibiotic dosing: Standard-dose amoxicillin-clavulanate is insufficient for treatment failures—must use high-dose formulation 1

3. Stopping intranasal corticosteroids: These should be continued throughout antibiotic therapy and beyond to control inflammation 1, 2

4. Ordering unnecessary imaging: CT is not indicated for uncomplicated cases and cannot distinguish bacterial from viral infection 3

5. Relying on oral antihistamines alone: These have modest decongestant action and are less effective than intranasal corticosteroids for congestion 2, 5, 6